Hoboken University Hospital

All Charges

Charge

Type

Setting

Price

PHENYLEPHRINE 10 MG/ML INJ

Facility

$20.97

Service Code	HCPCS J2371
Hospital Charge Code	60627464
Hospital Revenue Code	636
Min. Negotiated Rate	$3.15
Max. Negotiated Rate	$5.07
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$5.07
Rate for Payer: Qualcare PPO/HMO/WC	$3.15

PHENYLEPHRINE 2.5% OPTH 15ML

Facility

$723.60

Service Code	NDC 42702010210
Hospital Charge Code	606361041
Hospital Revenue Code	250
Min. Negotiated Rate	$108.54
Max. Negotiated Rate	$108.54
Rate for Payer: Qualcare PPO/HMO/WC	$108.54

PHENYLEPHRINE 2.5% OPTH 15ML

Facility

$723.60

Service Code	NDC 42702010210
Hospital Charge Code	606361041
Hospital Revenue Code	250
Min. Negotiated Rate	$20.55
Max. Negotiated Rate	$361.80
Rate for Payer: Aetna Commercial	$274.97
Rate for Payer: Aetna Medicare Advantage	$217.08
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$184.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$184.52
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$184.52
Rate for Payer: Cigna Commercial	$361.80
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$188.14
Rate for Payer: Oxford Commercial	$144.72
Rate for Payer: Qualcare PPO/HMO/WC	$108.54
Rate for Payer: UnitedHealthcare Commercial	$144.72
Rate for Payer: UnitedHealthcare Community & State	$22.87
Rate for Payer: Wellpoint Medicaid Managed Care	$20.55

PHENYLEPHRINE HCL SOL DPH 10%

Facility

$194.97

Service Code	NDC 42702010305
Hospital Charge Code	60628077
Hospital Revenue Code	250
Min. Negotiated Rate	$29.25
Max. Negotiated Rate	$29.25
Rate for Payer: Qualcare PPO/HMO/WC	$29.25

PHENYLEPHRINE HCL SOL DPH 10%

Facility

$194.97

Service Code	NDC 42702010305
Hospital Charge Code	60628077
Hospital Revenue Code	250
Min. Negotiated Rate	$5.54
Max. Negotiated Rate	$97.48
Rate for Payer: Aetna Commercial	$74.09
Rate for Payer: Aetna Medicare Advantage	$58.49
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.72
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.72
Rate for Payer: Cigna Commercial	$97.48
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$50.69
Rate for Payer: Oxford Commercial	$38.99
Rate for Payer: Qualcare PPO/HMO/WC	$29.25
Rate for Payer: UnitedHealthcare Commercial	$38.99
Rate for Payer: UnitedHealthcare Community & State	$6.16
Rate for Payer: Wellpoint Medicaid Managed Care	$5.54

PHENYLEPHRINE NASAL 0.25% SOLN

Facility

$30.08

Service Code	NDC 24134803
Hospital Charge Code	6004212
Hospital Revenue Code	251
Min. Negotiated Rate	$0.85
Max. Negotiated Rate	$15.04
Rate for Payer: Aetna Commercial	$11.43
Rate for Payer: Aetna Medicare Advantage	$9.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$7.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$7.67
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$7.67
Rate for Payer: Cigna Commercial	$15.04
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$7.82
Rate for Payer: Oxford Commercial	$6.02
Rate for Payer: Qualcare PPO/HMO/WC	$4.51
Rate for Payer: UnitedHealthcare Commercial	$6.02
Rate for Payer: UnitedHealthcare Community & State	$0.95
Rate for Payer: Wellpoint Medicaid Managed Care	$0.85

PHENYLEPHRINE NASAL 0.25% SOLN

Facility

$30.08

Service Code	NDC 24134803
Hospital Charge Code	6004212
Hospital Revenue Code	251
Min. Negotiated Rate	$4.51
Max. Negotiated Rate	$4.51
Rate for Payer: Qualcare PPO/HMO/WC	$4.51

PHENYLEPHRINE NASAL 0.5% SPR

Facility

$43.48

Service Code	NDC 24135301
Hospital Charge Code	60628081
Hospital Revenue Code	250
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$21.74
Rate for Payer: Aetna Commercial	$16.52
Rate for Payer: Aetna Medicare Advantage	$13.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.09
Rate for Payer: Cigna Commercial	$21.74
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.30
Rate for Payer: Oxford Commercial	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$6.52
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: UnitedHealthcare Community & State	$1.37
Rate for Payer: Wellpoint Medicaid Managed Care	$1.23

PHENYLEPHRINE NASAL 0.5% SPR

Facility

$43.48

Service Code	NDC 24135301
Hospital Charge Code	60628081
Hospital Revenue Code	250
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$6.52
Rate for Payer: Qualcare PPO/HMO/WC	$6.52

PHENYLEPHRINE NASAL 1% SOLN

Facility

$43.48

Service Code	NDC 24135202
Hospital Charge Code	6004261
Hospital Revenue Code	251
Min. Negotiated Rate	$1.23
Max. Negotiated Rate	$21.74
Rate for Payer: Aetna Commercial	$16.52
Rate for Payer: Aetna Medicare Advantage	$13.04
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$11.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$11.09
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$11.09
Rate for Payer: Cigna Commercial	$21.74
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$11.30
Rate for Payer: Oxford Commercial	$8.70
Rate for Payer: Qualcare PPO/HMO/WC	$6.52
Rate for Payer: UnitedHealthcare Commercial	$8.70
Rate for Payer: UnitedHealthcare Community & State	$1.37
Rate for Payer: Wellpoint Medicaid Managed Care	$1.23

PHENYLEPHRINE NASAL 1% SOLN

Facility

$43.48

Service Code	NDC 24135202
Hospital Charge Code	6004261
Hospital Revenue Code	251
Min. Negotiated Rate	$6.52
Max. Negotiated Rate	$6.52
Rate for Payer: Qualcare PPO/HMO/WC	$6.52

PHENYLEPHRINE SOL OPH 2.5% 5ML

Facility

$408.37

Service Code	NDC 17478020115
Hospital Charge Code	6004246
Hospital Revenue Code	251
Min. Negotiated Rate	$61.26
Max. Negotiated Rate	$61.26
Rate for Payer: Qualcare PPO/HMO/WC	$61.26

PHENYLEPHRINE SOL OPH 2.5% 5ML

Facility

$408.37

Service Code	NDC 17478020115
Hospital Charge Code	6004246
Hospital Revenue Code	251
Min. Negotiated Rate	$11.60
Max. Negotiated Rate	$204.19
Rate for Payer: Aetna Commercial	$155.18
Rate for Payer: Aetna Medicare Advantage	$122.51
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$104.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$104.13
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$104.13
Rate for Payer: Cigna Commercial	$204.19
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$106.18
Rate for Payer: Oxford Commercial	$81.67
Rate for Payer: Qualcare PPO/HMO/WC	$61.26
Rate for Payer: UnitedHealthcare Commercial	$81.67
Rate for Payer: UnitedHealthcare Community & State	$12.90
Rate for Payer: Wellpoint Medicaid Managed Care	$11.60

PHENYTOIN 100 MG / 2 ML INJ

Facility

$9.25

Service Code	HCPCS J1165
Hospital Charge Code	60627743
Hospital Revenue Code	636
Min. Negotiated Rate	$0.26
Max. Negotiated Rate	$4.62
Rate for Payer: Aetna Commercial	$3.52
Rate for Payer: Aetna Medicare Advantage	$2.77
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$2.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$2.36
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$2.36
Rate for Payer: Cigna Commercial	$4.62
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.24
Rate for Payer: Qualcare PPO/HMO/WC	$1.39
Rate for Payer: UnitedHealthcare Community & State	$0.29
Rate for Payer: Wellpoint Medicaid Managed Care	$0.26

PHENYTOIN 100 MG / 2 ML INJ

Facility

$9.25

Service Code	HCPCS J1165
Hospital Charge Code	60627743
Hospital Revenue Code	636
Min. Negotiated Rate	$1.39
Max. Negotiated Rate	$2.24
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$2.24
Rate for Payer: Qualcare PPO/HMO/WC	$1.39

PHENYTOIN 100 MG ER CAP

Facility

$4.00

Service Code	NDC 71036940
Hospital Charge Code	6022735
Hospital Revenue Code	251
Min. Negotiated Rate	$0.60
Max. Negotiated Rate	$0.60
Rate for Payer: Qualcare PPO/HMO/WC	$0.60

PHENYTOIN 100 MG ER CAP

Facility

$4.00

Service Code	NDC 71036940
Hospital Charge Code	6022735
Hospital Revenue Code	251
Min. Negotiated Rate	$0.11
Max. Negotiated Rate	$2.00
Rate for Payer: Aetna Commercial	$1.52
Rate for Payer: Aetna Medicare Advantage	$1.20
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.02
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.02
Rate for Payer: Cigna Commercial	$2.00
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.04
Rate for Payer: Oxford Commercial	$0.80
Rate for Payer: Qualcare PPO/HMO/WC	$0.60
Rate for Payer: UnitedHealthcare Commercial	$0.80
Rate for Payer: UnitedHealthcare Community & State	$0.13
Rate for Payer: Wellpoint Medicaid Managed Care	$0.11

PHENYTOIN 250 MG / 5 ML INJ

Facility

$13.27

Service Code	HCPCS J1165
Hospital Charge Code	60627744
Hospital Revenue Code	636
Min. Negotiated Rate	$1.99
Max. Negotiated Rate	$3.21
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.21
Rate for Payer: Qualcare PPO/HMO/WC	$1.99

PHENYTOIN 250 MG / 5 ML INJ

Facility

$13.27

Service Code	HCPCS J1165
Hospital Charge Code	60627744
Hospital Revenue Code	636
Min. Negotiated Rate	$0.38
Max. Negotiated Rate	$6.63
Rate for Payer: Aetna Commercial	$5.04
Rate for Payer: Aetna Medicare Advantage	$3.98
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$3.38
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$3.38
Rate for Payer: Cigna Commercial	$6.63
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$3.21
Rate for Payer: Qualcare PPO/HMO/WC	$1.99
Rate for Payer: UnitedHealthcare Community & State	$0.42
Rate for Payer: Wellpoint Medicaid Managed Care	$0.38

PHENYTOIN 50 MG CHEW TAB

Facility

$7.30

Service Code	NDC 71000740
Hospital Charge Code	60627742
Hospital Revenue Code	250
Min. Negotiated Rate	$1.09
Max. Negotiated Rate	$1.09
Rate for Payer: Qualcare PPO/HMO/WC	$1.09

PHENYTOIN 50 MG CHEW TAB

Facility

$7.30

Service Code	NDC 71000740
Hospital Charge Code	60627742
Hospital Revenue Code	250
Min. Negotiated Rate	$0.21
Max. Negotiated Rate	$3.65
Rate for Payer: Aetna Commercial	$2.77
Rate for Payer: Aetna Medicare Advantage	$2.19
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$1.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$1.86
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$1.86
Rate for Payer: Cigna Commercial	$3.65
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$1.90
Rate for Payer: Oxford Commercial	$1.46
Rate for Payer: Qualcare PPO/HMO/WC	$1.09
Rate for Payer: UnitedHealthcare Commercial	$1.46
Rate for Payer: UnitedHealthcare Community & State	$0.23
Rate for Payer: Wellpoint Medicaid Managed Care	$0.21

PHENYTOIN (DILANTIN)

Facility

$91.10

Service Code	HCPCS 80185
Hospital Charge Code	39900007
Hospital Revenue Code	301
Min. Negotiated Rate	$2.59
Max. Negotiated Rate	$156.00
Rate for Payer: Aetna Commercial	$36.04
Rate for Payer: Aetna Medicare Advantage	$42.93
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$48.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$48.06
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.25
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$31.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$48.06
Rate for Payer: Cigna Commercial	$45.55
Rate for Payer: Cigna Medicare Advantage	$13.25
Rate for Payer: Clover Medicare Advantage	$12.59
Rate for Payer: EmblemHealth Commercial	$39.75
Rate for Payer: Humana Medicare Advantage	$13.65
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.25
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$23.69
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$13.66
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$10.60
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.25
Rate for Payer: Wellcare Medicare Advantage	$13.25
Rate for Payer: Wellpoint Medicaid Managed Care	$2.59

PHENYTOIN (DILANTIN)

Facility

$91.10

Service Code	HCPCS 80185
Hospital Charge Code	39900007
Hospital Revenue Code	301
Min. Negotiated Rate	$13.66
Max. Negotiated Rate	$13.66
Rate for Payer: Qualcare PPO/HMO/WC	$13.66

PHENYTOIN,FREE

Facility

$390.00

Service Code	HCPCS 80186
Hospital Charge Code	39900008
Hospital Revenue Code	301
Min. Negotiated Rate	$58.50
Max. Negotiated Rate	$58.50
Rate for Payer: Qualcare PPO/HMO/WC	$58.50

PHENYTOIN,FREE

Facility

$390.00

Service Code	HCPCS 80186
Hospital Charge Code	39900008
Hospital Revenue Code	301
Min. Negotiated Rate	$11.01
Max. Negotiated Rate	$195.00
Rate for Payer: Aetna Commercial	$37.43
Rate for Payer: Aetna Medicare Advantage	$44.58
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Indemnity	$49.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Managed Care	$49.91
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) Medicare Advantage	$13.76
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) NJ Health	$31.35
Rate for Payer: Blue Cross Blue Shield of New Jersey (Horizon) PPO	$49.91
Rate for Payer: Cigna Commercial	$195.00
Rate for Payer: Cigna Medicare Advantage	$13.76
Rate for Payer: Clover Medicare Advantage	$13.07
Rate for Payer: EmblemHealth Commercial	$41.28
Rate for Payer: Humana Medicare Advantage	$14.17
Rate for Payer: Longevity Health Plan of New Jersey Medicare Advantage	$13.76
Rate for Payer: MagnaCare PPO/Direct Plus/Exchange/WC	$101.40
Rate for Payer: Oxford Commercial	$156.00
Rate for Payer: Qualcare PPO/HMO/WC	$58.50
Rate for Payer: UnitedHealthcare Commercial	$156.00
Rate for Payer: UnitedHealthcare Community & State	$11.01
Rate for Payer: UnitedHealthcare Medicare Advantage	$13.76
Rate for Payer: Wellcare Medicare Advantage	$13.76
Rate for Payer: Wellpoint Medicaid Managed Care	$11.08

Know your out-of-pocket cost for care.

All Charges